- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $72.06 / $74.54 / $454.23
| Facility | 26 | $72.06 | $74.54 | $454.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $119.18 / $202.31
| Professional | | $112.32 | $119.18 | $202.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.70 / $172.73 / $272.98
| Professional | | $44.70 | $172.73 | $272.98 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $103.82 / $103.82 / $103.82
| Facility | 26 | $103.82 | $103.82 | $103.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.39 / $197.55 / $340.27
| Professional | | $114.39 | $197.55 | $340.27 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $198.65 / $464.00 / $464.00
| Facility | 26 | $198.65 | $464.00 | $464.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.00 / $1,114.00 / $1,114.00
| Professional | | $1,114.00 | $1,114.00 | $1,114.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.19 / $182.12 / $349.44
| Professional | | $132.19 | $182.12 | $349.44 |